[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years.

The treatment of supraglottic carcinoma remains a controversial issue. Five accepted surgical and non-surgical oncological treatments have been currently established: standard horizontal supraglottic laryngectomy (HSL), supraglottic CO2 laser microsurgery (TLM), transoral robotic surgery, radiotherapy alone and radiotherapy in combination with chemotherapy. Some studies have shown that complications of head and neck surgeries increase significantly in patients over 65 years compared to younger patients. We designed a retrospective analysis to assess the rate of complications and functional outcomes of patients treated by TLM and HSL in cases of T1-T3 supraglottic squamous cell carcinomas (SCC) in a tertiary University Hospital. Results were compared between patients younger and older than 65 years. We found significant differences in the rate of aspiration pneumonia (p = 0.026), mean time to decannulation (p = 0.001) and mean hospital stay (p = 0.007) in patients treated by TLM, which was higher and longer in the group of patients over 65 years of age. Regarding HPL, we only found significant differences in the mean time to decannulation (p = 0.001), which was longer in the group of patients younger than 65 years. According to our results, TLM or HPL can both be a safe surgical option for patients older than 65 years, but previous evaluation of lung function before surgery is mandatory because of an increased risk of aspiration pneumonia in patients with lung problems, especially when treated by TLM. Concerning functional outcomes in patients older than 65 years, TLM reduces the postoperative rate of tracheostomy, mean time required for decannulation and mean hospital stay compared with HPL. However, no significant difference in the occurrence of aspiration pneumonia, dysphagia or in the mean length of NGT feeding was found.

Improved mechanical stability of HKUST-1 in confined nanospace.

One of the main concerns in the technological application of several metal-organic frameworks (MOFs) relates to their structural instability under pressure (after a conforming step). Here we report for the first time that mechanical instability can be highly improved via nucleation and growth of MOF nanocrystals in the confined nanospace of activated carbons.

The Vigo grommet trainer.

INTRODUCTION: Transtympanic grommet placement is perhaps the most common otologic outpatient procedure and is the junior resident's first step in otologic surgery. Drain placement requires a high level of skill and only after painstaking practice, will the young physician be prepared to perform the procedure. TECHNICAL NOTE: We describe a home-made training model for grommet placement, consisting of a wooden base holding a syringe, with a sheet of latex simulating the tympanic membrane. RESULTS: The model is cheap and easy to build. It allows ear tube (grommet) placement to be simulated in a practical and risk-free manner. The technique is reproducible, allowing the young physician to develop his or her skills without patient involvement. CONCLUSION: Although a simulator cannot perfectly replicate surgery, the Vigo grommet trainer is an excellent tool to provide valuable practice in acquiring and developing the skills needed to perform drain placement in the operating theater.

Use of eutectic mixtures for preparation of monolithic carbons with CO2-adsorption and gas-separation capabilities.

With global warming becoming one of the main problems our society is facing nowadays, there is an urgent demand to develop materials suitable for CO2 storage as well as for gas separation. Within this context, hierarchical porous structures are of great interest for in-flow applications because of the desirable combination of an extensive internal reactive surface along narrow nanopores with facile molecular transport through broad "highways" leading to and from these pores. Deep eutectic solvents (DESs) have been recently used in the synthesis of carbon monoliths exhibiting a bicontinuous porous structure composed of continuous macroporous channels and a continuous carbon network that contains a certain microporosity and provides considerable surface area. In this work, we have prepared two DESs for the preparation of two hierarchical carbon monoliths with different compositions (e.g., either nitrogen-doped or not) and structure. It is worth noting that DESs played a capital role in the synthesis of hierarchical carbon monoliths not only promoting the spinodal decomposition that governs the formation of the bicontinuous porous structure but also providing the precursors required to tailor the composition and the molecular sieve structure of the resulting carbons. We have studied the performance of these two carbons for CO2, N2, and CH4 adsorption in both monolithic and powdered form. We have also studied the selective adsorption of CO2 versus CH4 in equilibrium and dynamic conditions. We found that these materials combined a high CO2-sorption capacity besides an excellent CO2/N2 and CO2/CH4 selectivity and, interestingly, this performance was preserved when processed in both monolithic and powdered form.

Ethanol steam reforming on Ni/Al2O3 catalysts: effect of the addition of Zn and Pt.

Ni-based catalysts supported on Zn-modified alumina were investigated in the ethanol steam reforming reaction. A commercial γ-alumina was impregnated with different amounts of zinc nitrate (0, 2, 5, 10, 15, 20 wt.% on Zn basis), calcined, and then impregnated with nickel nitrate aqueous solutions. The samples were characterized by a number of techniques: N(2) adsorption at 77 K, X-ray diffraction (XRD), transmission electron microscopy (TEM), X-ray fluorescence (XRF), and temperature-programmed reduction (TPR). Their catalytic behavior in the ethanol steam reforming reaction was studied at 873 K, with a H(2)O/ethanol ratio of 5:1. Two effects of the presence of Zn were detected. On the one hand, zinc modifies the surface structure and the surface chemistry of the catalysts by formation of zinc aluminates, and on the other hand, zinc oxide can be reduced to metallic zinc under reaction conditions, thus modifying the catalytic properties of the active phase. The presence of Zn increases the ethanol conversion to gaseous compounds as compared with the catalyst supported on the Zn-free commercial alumina. The addition of a small amount of Pt (1 wt.%) causes a beneficial effect in the reaction. When Ni catalysts were used without a previous reduction treatment, ethylene was formed in high amounts; however, the Pt-Ni catalysts need no reduction pre-treatment to achieve high H(2) yields (close to 70%) and showed a high stability versus time on stream because of the control of the production of ethylene, a coke precursor.

Comparison of nanostructured titania matrices obtained by carbon template and sol-gel methods for controlled release of fluoxetine.

Two types of titania matrix were investigated as a support for the prolonged drug delivery of the antidepressant fluoxetine. Sample MT was synthesized using carbon template and consisted of titania microtubes on which then fluoxetine was adsorbed. Sample SG was synthesized by the sol-gel method when the drug was added during the reaction. The morphology of the powder surfaces was found to be different: nanotubes versus almost spherical particles with much larger surface area of SG and smaller pores. The relative degrees of hydroxyl coverage of the surface were studied by FTIR-spectroscopy and were found to be much larger for the sol-gel complex. Theoretical modeling was applied to consider possible interactions between the drug and the matrices. The liberation of the drug was proved to be faster from complex MT and was attributed to weaker drug-matrix interactions in combination with larger pore size.

Influence of water/alkoxide ratio in the synthesis of nanosized sol-gel titania on the release of phenytoin.

The sol-gel method was used to synthesize inorganic reservoirs with encapsulated antiepileptic drug phenytoin. The drug release profile was shown to depend on the morphology and surface properties of the matrix. A parameter of the synthesis such as water/alkoxide ratio r(w) was varied in order to investigate its influence on the matrix properties and as a result on the drug release profile. It was found that the specific surface area and crystallization degree decrease with an increase of r(w), whereas the hydroxyl group coverage increases with an increase of r(w). Drug release kinetics studies revealed that the initial release rate increases with an increase of water content in the reaction, whereas the long time release rate first slightly increases with an increase of water content from 4 to 8 and then decreases for r(w) = 16. The interplay of different parameters of the matrix is shown to be responsible for such a dependence and is discussed in the Article.

A site energy distribution function from Toth isotherm for adsorption of gases on heterogeneous surfaces.

A site energy distribution function based on a condensation approximation method is proposed for gas-phase adsorption systems following the Toth isotherm. The proposed model is successfully applied to estimate the site energy distribution of three pitch-based activated carbons (PA, PFeA and PBA) developed in our laboratory and also for other common adsorbent materials for different gas molecules. According to the proposed model the site energy distribution curves of the activated carbons are found to be exponential for hydrogen at 77 K. The site energy distribution of some of the activated carbon fibers, ambersorb, Dowex optipore, 13X Zeolite for different adsorbate molecules represents a quasi-Gaussian curve with a widened left hand side, indicating that most sites have adsorption energies lower than a statistical mean value.

[Inhaled anesthesia through a device for noninvasive continuous positive airway pressure ventilation for upper digestive endoscopy in pediatric patients]. / Anestesia inhalatoria mediante un dispositivo de ventilación no invasiva tipo "CPAP sin respirador" para endoscopia digestiva alta en pacientes pediátricos.

OBJECTIVE: The demand for sedation for pediatric diagnostic procedures performed outside operating rooms has increased considerably, but the ideal method to choose has been the subject of debate. The aim of this study was to assess the efficacy of using a device for continuous positive airway pressure, connected to a Mapleson D circuit and a nasopharyngeal tube as the interface, in order to ventilate and administer sevoflurane for upper digestive tract endoscopy in children. MATERIAL AND METHODS: Prospective cohort study of children undergoing upper digestive tract endoscopy. We recorded epidemiologic variables, heart rate, mean arterial pressure, arterial oxygen saturation and procedure-related adverse events before, during and 10 minutes after the procedure. Time spent in the recovery room was also recorded. The endoscopist asked the patients about their level of satisfaction and whether they had noticed any irritating smell or gas smell. RESULTS: Data was collected on 29 patients (17 boys, 12 girls) with a mean (SD) age of 4.2 (3.9) years. The mean duration of endoscopy was 15 (7) minutes. Arterial oxygen saturation below 92% during the procedure did not occur and the endoscopic exploration was completed satisfactorily with this technique in 28 patients (96%). All were discharged from the recovery room within 30 minutes. The endoscopist reported that the technique was considered satisfactory in all cases, although 2 children noted an anesthetic "gas" smell. CONCLUSIONS: A modified Mapleson D circuit and nasopharyngeal tube can be used effectively as an interface for noninvasive ventilation and administration of sevoflurane during upper digestive endoscopy in pediatric patients.

Catalytic nanomedicine: a new field in antitumor treatment using supported platinum nanoparticles. In vitro DNA degradation and in vivo tests with C6 animal model on Wistar rats.

Novel nanostructured TiO2 and SiO2 based biocatalysts, with 3-4 wt. % of Pt have been developed. The obtained materials exhibit a high surface area together with a broad pore size distribution. The method of synthesis allowed obtaining high dispersed platinum metal nanoparticles. In vitro DNA reactivity test of the biocatalysts were carried out by electrophoresis and formation of DNA adducts was observed. The most active biocatalyst was H2PtCl6/SiO2. These biocatalysts were also tested in an experimental model of C6 brain tumours in Wistar rats. Administration of the material was made by stereotactic brain surgery to place it directly in the malignant tissue. A significant decrease in tumour size and weight as well as morphologic changes in cancer cells were observed.

Spectroscopic and microcalorimetric study of a TiO(2)-supported platinum catalyst.

This paper reports a CO adsorption study on a Pt/TiO(2) catalyst reduced at two different temperatures, 473 and 773 K, followed by in situ infrared spectroscopy and adsorption microcalorimetry. The study is complemented with XPS characterization of the reduced catalysts.

Is there any microporosity in ordered mesoporous silicas?

The porous structure of nanostructured silicas MCM-41 and SBA-15 has been characterized using N2 adsorption at 77 K, before and after n-nonane preadsorption, together with immersion calorimetry into liquids of different molecular dimensions. Selective blocking of the microporosity with n-nonane proves experimentally that MCM-41 is exclusively mesoporous while SBA-15 exhibits both micro- and mesopores. Additionally, N2 adsorption experiments on the preadsorbed samples show that the microporosity on SBA-15 is located in intrawall positions, the micropore volume accounting for only approximately 7-8 % of the total pore volume. Calorimetric measurements into n-hexane (0.43 nm), 2-methylpentane (0.49 nm), and 2,2-dimethylbutane (0.56 nm) estimate the size of these micropores to be < or = 0.56 nm.

Bloqueo motor completo con ropivacaína epidural en el postoperatorio de un paciente con distrofia muscular de Duchenne / Complete motor blockade with epidural ropivacaine in the post-operative of a patient with Duchenne muscular dystrophy

Los pacientes afectos de distrofia muscular de Duchennepresentan un alto riesgo de complicaciones anestésicas. Se han descrito muy pocos casos de anestesia epidural enesta entidad. Presentamos un caso de anestesia combinada(propofol y remifentanilo intravenoso más ropivacaína epidural)para cirugía traumatológica, sin incidencias intraoperatorias,pero que en el postoperatorio presentó bloqueomotor completo en respuesta a la administración de ropivacaína0, 18% en perfusión epidural continua. Se discutela posibilidad de un aumento de sensibilidad a los anestésicoslocales en cuanto a la producción de bloqueo motor en esta patología

Patients with Duchenne muscular dystrophy present ahigh risk of anesthetic complications. Very few cases havebeen described of epidural anesthesia in this condition. Wepresent a case of combined anesthesia (IV propofol and remifentanylplus epidural ropivacaine) for a traumatologicalsurgery. There were no intraoperatory complications, butthe patient developed a complete post-operative motorblockade in response to the administration of ropivacaine0. 18% with continuous epidural perfusion. A potential increaseof the sensitivity to local anesthetics as the explanationof the motor blockade in this patient is discussed

Anestesia regional en pediatría: bloqueos centrales. Bloqueo del miembro superior / Paediatric regional anaesthesia: central blockade. Upper extremity blockade

En la actualidad, se considera que la anestesia regional es una herramienta valiosa y segura que proporciona una analgesia de alta calidad en el paciente pediátrico. Toda la variedad de bloqueos centrales y periféricos usados en el adulto, pueden ser usados también pediatría con seguridad. Revisamos las técnicas anestéticas regionales más frecuentemente realizadas en el paciente pediátrico, y aspectos como las consideraciones anatómicas y fisiológicas en el niño, seguridad, beneficios, así como dosificación y toxicidad de los anestésicos locales (AU)

Análisis coste/efectividad de tres técnicas de analgesia epidural en el tratamiento del dolor postoperatorio pediátrico / Cost-effectiveness analysis of three epidural analgesia techniques for the management of paediatric postoperative pain

Objetivos: Comparación de la eficiencia de tres técnicas de analgesia epidural para tratamiento del dolor postoperatorio en niños: tratamiento con analgesia epidural con bolos de morfina cada 8 horas (grupo MB), analgesia epidural continua con una mezcla de lidocaína y fentanilo (grupo PC) o analgesia epidural administrada a través de una bomba de PCA de lidocaína y fentanilo (grupo PCA).Métodos: Estudio económico predictivo sobre una hipotética cohorte de 250 individuos pediátricos afectados por dolor postoperatorio moderado-severo en un Hospital de Tercer Nivel. Se aplicaron los precios de mercado a los costes asociados a cada técnica. Se calcularon los ratios coste/efectividad con los datos sobre seguridad y efectividad de cada técnica publicados en la literatura y los obtenidos en el estudio. Resultados: Los costes totales asociados a cada técnica fueron superiores en el grupo PCA (5.353 euros) y PC (5.046,7 euros) comparado con el grupo MB (3.249,8 euros), sin embargo, la mayor efectividad del grupo PCA (220 pacientes) frente al grupo PC (145 pacientes) o el MB (104 pacientes) provocó que el coste por tratamiento adecuado fuese netamente menor en el grupo PCA (24,33 euros/paciente) que en el grupo PC (32,14 euros/paciente) o el MB (32,25 euros/paciente). Conclusiones: La introducción de una nueva tecnología como la PCA en el tratamiento del dolor postoperatorio pediátrico supone un encarecimiento del servicio asistencial prestado. La pertinente evaluación económica de dicha tecnología permitió demostrar que dicho encarecimiento se tradujo en un claro beneficio de los pacientes tratados con una mayor eficiencia (AU)

Nearly space-filling fractal networks of carbon nanopores.

Small-angle x-ray scattering, nitrogen adsorption, and scanning tunneling microscopy show that a series of activated carbons host an extended fractal network of channels with dimension D(p) = 2.8-3.0 (pore fractal), channel width 15-20 A (lower end of scaling), network diameter 3000-3400 A (upper end of scaling), and porosity of 0.3-0.6. We interpret the network as a stack of quasiplanar invasion percolation clusters, formed by oxidative removal of walls between closed voids of diameter of approximately 10 A and held in registry by fibrils of the biological precursor, and point out unique applications.

[An experimental model of hepatointestinal transplant in the pig with clinical applications]. / Modelo experimental de trasplante hepatointestinal en el cerdo adaptado a aplicación clínica.

A model of experimental hepatointestinal transplant in pigs, with clinical applications is presented. Ten animals received a graft composed by the liver and the full length of the small bowel. Two pigs died during the transplant and in eight the surgical procedure was well tolerated with a good revascularization of the grafts. The coagulation parameters were normal after the transplant and only minor biochemical disturbances were found. The main difficulties of the surgical technique are related with the poor tolerance of the pig to the portal and caval clamping, and the close relationships of the duodenum, pancreas and distal colon, produced by the 360 degrees anti-clockwise bowel rotation around the mesenteric vessels. Clamping the supraceliac aorta during the implant of the graft keeps the animal hemodynamically stable and makes unnecessary the use of the more complicated veno venous shunt.

Donor vascular grafts for arterial reconstruction in pediatric liver transplantation.

The authors compared the results of 48 orthotopic liver transplantations (OLT) in which revascularization was achieved with a conduit interposed between the receptor aorta and the graft (vascular graft [VG] group) with those obtained for 56 OLT performed during the same period (1991 to 1994) in which end-to-end anastomosis (EEA) of the hepatic arteries or celiac trunk was used (EEA group). In the VG group, the interposed conduits were the cadaveric iliac artery (37) the living-donor saphenous vein (3), or nonthrombosed conduits from previous transplants (8) (7 iliac arteries, 1 saphenous vein). There were significant differences between the two groups with respect to recipient age, recipient weight, the retransplant:first transplant ratio, the number of emergency transplantations, the use of reduced-size grafts, and intraoperative transfusion requirements. Twenty-nine grafts in the VG group (60.4%) and 43 in the EEA group (76.7%) currently are functioning. The actuarial 3-year graft survival rates are 60% and 71.5% for the VG and EEA groups (P < .05), respectively. The rate of arterial thrombosis did not differ between the two groups. The authors conclude that, although EEA of the hepatic artery is still the preferred revascularization technique for OLT, revascularization of the liver graft by conduit interposition is safe when EEA is not possible. Reutilization of the interposed conduit during retransplantation proved to be safe in the absence of hepatic artery thrombosis.

Factores de riesgo y consecuencias sociales del embarazo en adolescentes

Se estudiaron 237 adolescentes gestantes que acudieron al Consultorio de Atención Integral para adolescentes embarazadas, en el Hospital Gineco-obstétrico Isidro Ayora (HGOIA) de Quito, Ecuador, durante un período de doce meses (septiembre de 1991 - octubre de 1992). Se investigaron los factores de riesgo social mediante el interrogatorio y entrevista de la paciente, su pareja y familia. Los datos se registraron en una historia clínica diseñada para el efecto, Las principales consecuencias encontradas fueron: deserción escolar, desocupación, trabajo mal remunerado, dependencia, abandono, uniones forzadas e inestables y control parenteral irregular.